I’m not insane (I’ve only lost my mind)

Imagine that you are locked up in an insane asylum. You are perfectly sane, or so you think. In fact, you have lived your life with the assumption that you are normal. Now, you are stuck inside a mental ward because the doctors have diagnosed you with a very serious mental illness.

The doctors think that you have to be isolated from the rest of society because you have been identified as a threat. And society has willingly abandoned you.

Inside the ward, you struggle to come to grips with your helplessness. Because you have no legal rights as a human, your movement is restricted and you are deprived of privacy for even your most basic daily activities. The nurses and attendants have complete control over you. You are shocked that they go on with their business without ever talking to you or even noticing you. They even talk about you in front of you in degrading terms as if you are incapable of comprehension. You cannot change your situation or station in life. If you commit the “grievous sin” of talking to the staff without first asking for permission, you suffer a merciless beating.

Understandably, you are scared and nervous, but you also believe you will be released soon if you act normal. You go about your daily life trying to convince others that you are not insane. Unfortunately, your every act is perceived as a symptom of your diagnosed insanity, which of course, leads you to even greater desperation. You come to realize the unspoken dictum in society that a psychiatrist’s diagnosis is seldom if ever reversed. In fact there is rarely an opportunity to even get a second opinion. With your institutionalization, you have been deprived of one of the most basic tenets of a democratic society; you have been handed a verdict with little chance of any sort of appeal.

Does this sound like a ludicrous run-of-the-mill plot from a low-budget potboiler? Surely, the scenario that I have painted is a little too far-fetched. Or, is it?

In the early Seventies, David Rosenhan, a professor of psychology at Stanford University in California, devised scientific experiments to answer an eerily similar question: how effective would professionally-trained caregivers be in separating the sane from the insane? In 1973, the results of his experiment were published in a research paper in the prestigious American scientific journal Science.

Let us took a closer look at what Rosenhan found. His experimental setup was elegantly simple. He planned to have eight normal volunteers, including himself, masquerade as psychiatric patients. These so-called fake patients would try to gain admittance to twelve psychiatric hospitals and if admitted, they would immediately revert to behaving what they perceived as “normal” to try to get out.

Rosenhan wanted to perform his experiment thoroughly and put a lot of thought into the design. The psychiatric hospitals were chosen carefully to represent a good geographical mix within the United States. Also, there was a mix of public and public hospitals, and both small and large ones in the experiment. What Rosenhan was striving to achieve was to test if there was any variance to detection of deception in different clinical settings.

In addition, Rosenhan chose his volunteers to represent what society generally considers “serious” individuals. One of the volunteers was a psychology student. Among others were a psychiatrist, a housewife, a painter, a pediatrician, and three psychologists. Five of the volunteers were men and three were women, so there was little gender disparity. None of the volunteers had ever experienced symptoms of any serious mental disorder, so their history gave them a clean chit too.

To keep from the fraud getting detected, volunteers were told to hide names and occupations when they visited the hospitals. An elaborate background story was created for each one of them. Upon arrival at the hospital, each fake patient complained that he or she had heard unfamiliar, muffled voices that uttered the words “empty,” “hollow,” and “thud”. These words were chosen deliberately because Rosenhan felt that they might be construed to existentially signify the meaningless of life, but by no means did they indicate any serious psychiatric disorder. Apart from these falsifications, the volunteers were instructed to provide truthful information to the consulting psychiatrists as long as their anonymity was preserved.

Before approaching the hospitals, the fake patients expressed concern that they would be exposed as frauds. Such anxiety, however, turned out to be completely unfounded. Each and every fake patient presented the same symptoms to psychiatrists in the twelve hospitals tested and not once was the deception detected! Interestingly, the most common diagnosis which occurred eleven times in frequency was schizophrenia. One psychiatrist diagnosed manic-depressive psychosis. Both of these conditions are usually adequate grounds for separating patients from the rest of society.

As part of the plan, once admitted, each fake patient acted as he or she normally would do as far as possible under the circumstances. Each attempted to engage both the patients and the staff in normal conversation as much as allowed. Visitors of these fake patients did not detect any behavioral changes during the stay. Remarkably, despite this observation by external sources, the notion that these fake patients might be sane (or recovering) was never even considered by the hospital staff. The fake patients were in a quandary because normal activities such as writing notes in a diary were judged to be typical symptoms of mental illness. Interestingly, it was common for the other genuine patients of the ward (for lack of a better description) to expose the fake patients as being sane!

If Rosenhan’s experiment presents a bleak picture to you, rest assured that there is a somewhat happy ending. Thankfully, all the volunteers were ultimately released with their “sanity” intact. Hospital administrators had been informed of the experiment prior to the undertaking to prevent the possibility of extended hospitality.

When word of the results of this experiment got out on the street, there was a ruckus. Staff at a very prestigious hospital that had not been part of the original experiment doubted that such serious inaccuracies could happen at their own establishment.

Rosenhan put this claim to the challenge. He told the staff of this hospital that as part of his study, he would send one or more fake patients in the following three months. However, this turned out to be no more than a bluff. No volunteers were sent by Rosenhan in that time-frame. Strikingly, even though no fake patients had been sent to the hospital, the staff examined 193 patients who were admitted for psychiatric treatment during this time and came to the conclusion that that forty-one were not real patients at all!

By this point, you may be wondering how this elaborate experiment concerns the rest of us, since it is unlikely that we will ever be treated for a serious psychiatric disorder. However, all of us will have to visit a physician at some time or other. Statistical studies have indicated that physicians are more likely to diagnose a healthy person as being sick as opposed to find that a sick person is healthy. So much for rational objectivity in the medical sciences!

What can we conclude from this analysis? We can not accuse all physicians of ignorance or malicious intent because that conclusion is a far stretch from the truth. However, we can also safely assume that the results of misdiagnosis are not equal in all cases. Obviously, it is better to treat a healthy person for a disease he or she does not have than to turn away a truly sick person with a clean chit of health. Overmedication or prescribing the wrong medicine is generally not as harmful as failing to detect a real disease. Understandably, physicians almost instinctively err on the side of caution.

The problem is that when a wrong diagnosis is made, it can be difficult to reverse. In the Rosenhan study, after the psychiatrists had diagnosed the fake patients with serious psychiatric disorders, the staff believed that they were patients and all normal activities were perceived as supporting the diagnosis. This tendency is known in psychology as a confirmation bias and it is fairly ubiquitous in our everyday lives.

How does a confirmation bias form? A proposition either preconceived or with mild support finds favor. Then, all information that supports the proposition is magnified in the mind. Any information that can be stretched to support the proposition is also accepted as additional confirmation. Information that directly contradicts the proposition are either ignored or avoided.

The confirmation bias comes to us naturally. Instead of looking dispassionately at evidence, we are programmed to unconsciously sort through data to find patterns that support our theories. Every time the gambler wins a jackpot, it confirms his belief that he is talented. If he loses, it is an unfortunate thought that has to be avoided and put at the back of the mind. Every dream that can be somehow made to fit in with reality is proof that the psychic has supernatural skills; thousands more that cannot be distorted to fit in with reality are either forgotten or explained away.

Even the nature of the information does not matter. The same data is used by the party in power to show that government is succeeding in improving the lives of citizens, and by the opposition to claim that the same citizens are worse of than they were before.

So, should we strive to be completely open-minded in our lives, then? I would argue that such a human does not exist. What I am advocating is that it is possible to train the mind to think critically to try to avoid conformation biases. A simple test is to ask ourselves what evidence we need to reevaluate our currently-held positions. Are we fairly flexible in our views? Do we need an insurmountable burden of evidence to even consider other alternate viewpoints?

All of us like to surround ourselves with those that agree with our views. When our views are uncontested, this allows us to safely stay within our own mental comfort-zones Personally speaking, I often find it difficult to be told that I am wrong and to accept this as a fact. However, to think rationally it is also necessary to be flexible and to consider opposing viewpoints. I know that this is easier said than done. There will always be those that seek to justify religious intolerance, gender bias, caste discrimination, or racism based on what they consider “evidence” that the cohort they belong to is superior to others.

Just take a moment to consider the terrifying power of biased thinking. What would happen if every judge selectively scrutinized evidence to convict an alleged criminal; if every leader rushed into war without heeding warnings from generals; and if every scientist abandoned new ideas that did not conform to rigid theories? That would be an insane world indeed!